Evaluation of a Command-line Parser-based Order Entry Pathway for the Department of Veterans Affairs Electronic Patient Record

Design: The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users’ satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System–Seattle Division participated in the evaluation. Results: Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language–based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 ± 4.52 minutes; P = 0.029). Compared with the graphical user interface, the command-line–based pathway was perceived as easier to learn (P < 0.01), was considered easier to use and faster (P < 0.01), and was rated better overall (P < 0.05). Conclusion: Physicians found the command-line interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer. ■ J Am Med Inform Assoc. 2001;8:476–498. CHRISTIAN LOVIS, MD, MPH, MICHAEL K. CHAPKO, PHD, DIANE P. MARTIN, PHD, THOMAS H. PAYNE, MD, MPH, ROBERT H. BAUD, PHD, PATTY J. HOEY, RPH, STEPHAN D. FIHN, MD, MPH D ow naded rom http/academ ic.p.com jam ia/article-act/8/5/486/795933 by gest on 16 M arch 2019 to be cost-effective.8 Besides mitigating errors due to writing and transcription, electronic order entry can be used as a vehicle to provide comprehensive medical information and decision support.9–12 Electronic order entry is the fundamental framework for the embedded guidelines designed to support the decision process of health care providers.13 One of the major challenges in designing the electronic patient record is to meet the needs of detailed documentation while keeping the burden on directcare providers within an acceptable range. Tightly controlled and structured data entry can be a major burden for health care providers because of high costs in time.14–15 There have been many reports on how difficult it is to introduce electronic order entry systems. The well-known story about the OSCAR system at a Calgary hospital,16 which turned into a battle of physicians against machines, is not unique. Computerized order entry is known to take more time than handwritten order entry, especially for admitting orders.17 The evolution of computer interfaces that use a mouse, menus, forms, and dialog boxes has simplified the use of computers, especially for novices. Command-line–oriented systems, while difficult for novices, are very efficient for experienced users. High-speed, robust natural language processing techniques simplify use of command-line systems and permit their use by novices. Such techniques are especially important in academic settings where turnover among residents and other health care providers is high. In 1998, the Department of Veterans Affairs (VA) Computerized Patient Record System (CPRS) was first released at a national level. The CPRS organizes and presents all relevant patient data to support clinical decision making. It allows clinicians to view and add patients’ data, make notes, and enter orders. It supports alerts, notifications, and guidelines. The CPRS became possible because of the extensive set of clinical and administrative applications in the Veterans Health Information Systems and Technology Architecture, VistA. The CPRS can be seen as a line of tightly integrated products that use open and distributed architectures and are able to support evolution and local adaptations. In a recent review of the implementation of the CPRS system at the VA Puget Sound Health Care System, one of the most common problems described by physicians was the time required to enter orders.18 The objective of the present project was to develop a simple and robust natural-language–based order entry pathway for an electronic patient record and determine its effects on order entry time and user satisfaction.